Activities of Daily Living in Residents of Nursing Home and Assisted Living Facilities: A Multilevel Analysis

Background The ability to perform activities of daily living (ADLs) is the most basic function for older adults living in long-term care (LTC). Various personal and institutional factors can be associated with functional performance in ADLs among LTC residents.

Purpose The purposes of this study were to examine the trajectory of functional performance in ADLs over time, the variance in functional performance that is attributable to individual and institutional variations, as well as the impact of individual and institutional characteristics on functional performance among residents living in LTC settings.

Methods This study was a secondary analysis of longitudinal data of 788 residents from 8 Nursing Home (NH) and 16 Assisted Living (AL) facilities from four cluster-randomized controlled trials. The independent variables included time nested within resident (level 1), resident characteristics including demographics, balance, cognition and length of stay in the long-term care setting (level 2), and facility characteristics including type of intervention and facility (level 3). The dependent variable was resident functional performance of ADLs (level 2) measured by Barthel Index. Covariates were determined based on prior research and bivariate analysis of the data. Multilevel modeling approach was used to distinguish resident and facility level variations on functional performance. Both Random Intercept (RI) and Random Coefficient models were examined, and model fit was compared using likelihood ratio difference. Inter-class correlation was reported to demonstrate the percentage of variance attributable to the resident and facility level variations, as well as the variance explained by covariates.

Results The 3-level RI model with covariates was a better fit to the data. Functional performance of ADLs declined over time, decreased as residents’ balance and cognition deteriorated and among those who lived longer in the long-term care facility. Functional performance of ADLs was higher among male, white and AL residents with higher education compared to their counterparts, while such difference decreased between male and female and increased between AL and NH residents over time. More than 78% of variance in function was accounted for by the resident (28%) and facility level (50.5%) variation, while the individual and institutional covariates captured around 20% of the variance, mostly from the facility level.

Discussion This study provided preliminary information to support the effects of individual and institutional characteristics on functional performance among long-term care residents. Attentions that are paid to improve balance, alleviate progression of cognitive decline, and reduce the length of stay in NH settings may hold promise for maintaining or improving functional performance in ADLs.